DNAR

Two years ago I contracted acute epiglottitis. This isn’t something you see very much these days because it’s usually caused by Haemophilus influenzae, and babies are vaccinated against this at birth. I’m too old to have been vaccinated, and in any case I am significantly immunosuppressed by my cancer and its treatment, so there is no guarantee that vaccinations w ouldprotect me very much, or previous exposure to infections either. I was feeling fine that morning, apart from a slight sore throat, but I recognised that I had stridor (noisy breathing caused by a narrowed airway) and I thought my wife had better take me to hospital. We drove to the Royal Surrey County Hospital in Guildford, my place of work, and they ushered me straight into Casualty. I really wasn’t expecting things to move so fast after that, because within minutes of arriving my airway obstructed completely. The last thing I remember before losing consciousness was somebody putting out a crash call. The other thing I remember was that asphyxiation wasn’t quite as frightening or awful as I would have expected.

The crash call goes out after somebody has just had a cardiac arrest, though if there is an experienced clinician around they might recognise the signs of impending death a little earlier, giving the team a slight head start. I was lucky that it was a Thursday morning and there was a Consultant ENT surgeon already there to sound the alert.

When the call goes out, half-a-dozen or so pagers carried by key personnel start beeping rapidly, followed by a distorted voice telling them where to go. As one of the junior physicians on call I used to carry one of these from time to time, and the adrenaline rush was usually enough to sustain me running down the hospital corridors and up the stairs until I arrived at the scene, completely exhausted, hoping that I wasn’t going to have to take over the cardiac massage before I had got my breath back, or give mouth-to-mouth to somebody who had just vomited (as they generally do).

In any hospital, there are always some patients who are expected to die, and makes no sense calling the crash team for them. But nobody wants to be the one not to call the team if they aren’t quite sure. Hence we have DNAR orders (Do Not Attempt Resuscitation) to clarify the situation with regard to those who should should just be allowed to get on with departing this world, peacefully and in their own time. We used to have little stickers on the corner of the notes, or perhaps an entry by the House Officer saying DNAR with a signature and a date. But a few years ago somebody in the Ministry of Health decided that it was a bit creepy having medical staff handing out death sentences, as they saw it, and thought it should be the patient’s decision. Unfortunately many patients have unrealistic ideas from watching hospital-based soap operas, and this can make for an awkward conversation.

I have heard agonised discussions between colleagues and other staff, about quality of life, prognosis, the psychological impact of discussing death or whatever. All nonsense. Despite it having somehow become standard to measure the value of costly treatment in QALY’s (Quality-Adjusted Life Years), you can’t actually measure somebody else’s quality of life. We all say things like “If I ever get like that, just shoot me”, and some people sign Advance Treatment Directives (“Living Wills”) just to make it clear. Happily these aren’t legally binding, as the goalposts tend to move bit by bit a colostomy / drip feeding / wheelchair / cancer treatment turns out not to be as bad as anticipated. For that matter, discussing death can be quite helpful, too, for both the patient and the team looking after them. Though some people don’t want to know (“What do you mean, you’re stopping my treatment? I haven’t got the new kitchen in yet.”).

Just to be clear, the main thing that matters when it comes to quality of life is having strong relationships and a supportive family.

But still nonsense when it comes to Advanced Life Support (what we used to call CPR) because the only thing that really matters is whether it is likely to work.

If somebody has just had a myocardial infarction (the technical term for what most people know as a heart attack or a coronary), one of the dangers is that the heart muscle can become irritable and suddenly switch from a steady rhythm to a disorganised state known as ventricular fibrillation where the fibres are no longer co-ordinated with each other (I’m told by cardiac surgeons that a fibrillating heart looks like a bag of worms, though I’ve never had the opportunity to see it without the rest of the chest in the way). In this state it can no longer pump, but a suitable DC electric shock will get the fibres back in synchrony again and restart the heart. Usually somebody needs to jump on the chest a bit while the defibrillator is being readied, but that is about it. If the patient keeps on going back into VF they will be in the coronary care unit by then with the defibrillator ready at the bedside, in which case you just need to wait until they have lost consciousness because otherwise the electric shock can be a bit unkind.

(For those with an ongoing risk of VF and other potentially fatal arrhythmias there is a device called an implantable cardioverter defibrillator (ICD) which is a bit like a beefed-up pacemaker and can deliver large enough shocks to the heart to get back into sinus rhythm (i.e. pumping again). I had a patient once with one of those who used to go into VF during the excitement of coitus. His cardiologist offered to review his drug regimen in case there was anything that could be done to prevent it, but he declined on the grounds that his wife enjoyed the additional thrill of the electric shock.)

There are a few other situations, such as major blood loss, where the patient can generally be retrieved. What these all have in common is that they are basically fit and reasonably well, and a single system (breathing, circulation, heart) has temporarily failed. Provided you can keep the brain oxygenated while you are dealing with the acute problem then things have a good chance of working out.

But what about all the other patients who collapse on the ward? The situation really isn’t the same when somebody who is already sick gets steadily sicker. One system after another starts to go. The kidneys and liver are failing and can no longer maintain homeostasis, the heart isn’t pumping very well, the lungs can barely get enough oxygen in. It is like a stack of dominos falling one after another. Finally the heart stops. Good luck to you if you thing you can restart it and even if you do it will only be for a few minutes. They are dead, and they are going to stay that way, and there isn’t anything you can do about it, so why put everybody (especially the family) through all that drama?

An experienced clinician will know who these patients are. They (and only they) are the ones who should have DNAR orders, and if they do pick up then the order can be rescinded (it is supposed to be regularly reviewed in any case). Otherwise we are just lying to the patients (and ourselves), pretending that we have powers that we don’t have and promising what is not in our gift.

It’s very simple really. If there is a reasonable chance that they can be resuscitated, then do it. If not, leave them alone.